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APPLICATION FOR PERMIT _ aA` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 Rt P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address Q L� City-14Lot Size PM r Owner's Name Address Phone ' ContractorAddress License No. Phone /t TYPE OF WELL/POMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t_ 171Industrial 11Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private. ❑ Gravel Pack ❑ Tracy r Type of Casing Specifications 1 M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout 11 Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by - i { Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION tir REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:. Residence J_ Commercial Other- r� Number of living units: AL Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method ofDlispy al Distance to nearest: Well I - - Foundation Property Line�.-±7�t1 y L9 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: � Well Foundation ' i ;� � Property Line i (=EPASGE PITS 11 Depth Size Number UIUIP ❑ Distance to nearest: Well Foundation /�f`'l Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and R rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must tail for all ye�17irinspections. mplete drawing on wverse side. f� '71 j signed X Title: ' j _ Date: v l FOR DEPARTMENT USE ONLY Application Accepted by Date `� Area ell Pit or Grout Inspection by Date Final Inspection by e Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca' 823-7104 " ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ) FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 1 _ ' 1 + EH 13-24 IREv.11H 57ry EH 14-29 V e 1 . .